Diagnostic significance of papillary structures and intranuclear inclusions in Hurthle-cell neoplasms of the thyroid.

Papillary structures and intranuclear inclusions, features which are not ordinarily associated with Hurthle-cell lesions, are occasionally noted within Hurthle-cell-rich aspirates. The diagnostic significance of these features in this setting, if any, is unknown. The purpose of this study was to determine whether these features are diagnostically useful. Specifically, since fine-needle aspiration cytology cannot distinguish between Hurthle-cell adenoma and carcinoma, we wanted to know whether the presence of either feature might aid in preoperatively assessing the likelihood of carcinoma vs. adenoma. We identified 12 cases in which a diagnosis of Hurthle-cell lesion was made by thyroid fine-needle aspiration biopsy. All cases had subsequent surgery. For every case, all cytology slides were reviewed for the presence or absence of papillary structures and intranuclear inclusions, after which the findings were correlated with the final surgical pathological diagnosis. Seven of the 12 cases had identifiable papillary structures, ranging from cases where papillary structures comprised the predominant architectural pattern to cases where rare papillary structures were found amidst a predominance of sheets and single Hurthle cells. Four of the 12 cases had intranuclear inclusions. In all cases, intranuclear inclusions were uncommon. Of 6 cases that proved to be Hurthle-cell carcinoma, 5 had papillary structures on the antecedent fine-needle aspirate cytology, and 2 had intranuclear inclusions. Of 6 cases that proved to be Hurthle-cell adenoma, 2 had papillary structures, and 2 had intranuclear inclusions. Papillary structures had a sensitivity of 83% for the presence of carcinoma, a specificity of 66%, a positive predictive value of 71%, and a negative predictive value of 80% (P = 0.2). Intranuclear inclusions had a sensitivity of 33%, a specificity of 66%, and positive and negative predictive values of 50%. Papillary structures are more common in Hurthle-cell aspirates than previously recognized. Their presence is not diagnostic of carcinoma, but neither does their absence rule out carcinoma. However, when found, the likelihood of an ultimate diagnosis of Hurthle-cell carcinoma is increased. On the other hand, intranuclear inclusions, when rare, appear to have no diagnostic value.